Episodic Women’s Health SOAP Note Template

Encounter date:

Patient Initials: Gender: Age: Race/Ethnicity:

Subjective

Reason for Seeking Health Care:

History of Present Illness (HPI):

Allergies (Drug/Food/Latex/Environmental/Herbal):

Current Medications (including over the counter medications):

Past Medical History (PMH):

OB/GYN History:

Past Surgical History:

Family Medical History:

Social History:

Review of Systems (ROS)

Focus on systems affecting women’s health and inquire about systems relevant to the reason for the visit)

Physical Examination

Vital Signs

General Appearance

Include physical exam of all relevant systems based on the reason for the visit and the HPI. Perform a cardiopulmonary exam on all patients regardless of the reason for seeking care.

Significant Data/Contributing Dx/Labs/Misc

Assessment

Differential Diagnoses (3 minimum)

Primary Diagnoses

Plan

For each primary diagnosis, include laboratory/diagnostic tests, therapeutic/pharmacological therapy, referrals, and follow-up ordered and patient education done for this visit.

Include age-appropriate health promotion/maintenance/screening needs.

Remember that for every S (reason for the visit), there must be an O, A, and P (relevant exam, diagnosis, and plan). Always sign your notes.

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense: ___________ Refill: _________________

No Substitution

Signature: ____________________________________________________________

Signature (with appropriate credentials): __________________________________________

References (must use current evidence-based guidelines used to guide the care [Mandatory])

5

Joseph, M. V. (2021). Episodic Women’s Health SOAP Note. Copyright ©